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On approval of the Rules for dynamic observation of patients with chronic diseases

Order of the Minister of Health of the Republic of Kazakhstan dated March 30, 2019 No. ҚР ДСМ-16. Registered in the Ministry of Justice of the Republic of Kazakhstan on April 8, 2019 No. 18474

      Order of the Minister of Health of the Republic of Kazakhstan dated March 30, 2019 No. ҚР ДСМ-16. Registered in the Ministry of Justice of the Republic of Kazakhstan on April 8, 2019 No. 18474

      Unofficial translation

      In accordance with subparagraph 127) of paragraph 1 of Article 7 of the Code of the Republic of Kazakhstan dated September 18, 2009 "On people’s health and healthcare system", I HEREBY ORDER:

      1. To approve the attached Rules for dynamic observation of patients with chronic diseases.

      2. The Department of organization of medical care of the Ministry of Health of the Republic of Kazakhstan, in the manner prescribed by law, to ensure:

      1) state registration of this order in the Ministry of Justice of the Republic of Kazakhstan;

      2) within ten calendar days from the date of the state registration of this order, sending of its copy in electronic form in the Kazakh and Russian languages to the Republican state enterprise on the basis of the right of economic management “Republican Legal Information Center” for official publication and inclusion in the Reference Control Bank of regulatory legal acts of the Republic of Kazakhstan;

      3) placement of this order on the Internet resource of the Ministry of Health of the Republic of Kazakhstan;

      4) within ten working days after the state registration of this order in the Ministry of Justice of the Republic of Kazakhstan, submission of information to the Department of Legal Services of the Ministry of Health of the Republic of Kazakhstan on implementation of measures provided for in subparagraphs 1), 2) and 3) of this paragraph.

      3. Vice Minister of Health of the Republic of Kazakhstan L.M. Aktayeva shall be authorized to oversee the execution of this order.

      4. This order shall come into force ten calendar days after the day of its first official publication.

      Minister of Health of the
      Republic of Kazakhstan Ye. Birtanov

  Approved
by the order of the Minister of Health of the Republic of Kazakhstan dated March 30, 2019 № ҚР ДСМ-16

Rules for dynamic observation of patients with chronic diseases

Chapter 1. General provisions

      1. These Rules for dynamic observation of patients with chronic diseases (hereinafter referred to as the Rules) are developed in accordance with subparagraph 127) of paragraph 1 of Article 7 of the Code of the Republic of Kazakhstan dated September 18, 2009 “On people’s health and healthcare system” (hereinafter - the Code) and determine the procedure for dynamic observation of patients with chronic diseases.

      2. The basic concepts used in these Rules are:

      1) primary health care (hereinafter referred to as PHC) - pre-medical or qualified medical care without round-the-clock medical supervision, including a range of available medical services provided at the level of a person, family and society;

      2) a subject matter specialist - a medical specialist with a higher medical education who has a certificate in a particular specialty;

      3) dynamic observation - systematic monitoring of the state of people’s health, as well as the provision of necessary medical care based on the results of this observation;

      4) clinical protocol - a document establishing the general requirements for provision of medical care to a patient in a particular disease or clinical situation;

      5) consultative and diagnostic assistance (hereinafter - CDA) – a specialized medical care, including with the use of high-tech medical services without round-the-clock medical supervision.

      3. Dynamic observation of patients with chronic diseases is carried out:

      according to the list of diseases subject to dynamic observation in primary health care organizations and within the framework of the disease management program, in accordance with the PHC Rules approved by the order of the Minister of Health and Social Development of the Republic of Kazakhstan dated April 28, 2015 No. 281 (registered in the Register of state registration of regulatory legal acts under No. 11268) (hereinafter referred to as Order 281);

      according to the list of diseases subject to dynamic observation within the framework of consultative and diagnostic assistance, in accordance with the CDA Rules, approved by the order of the Minister of Health and Social Development of the Republic of Kazakhstan dated July 28, 2015 No. 626 (registered in the Register of state registration of regulatory legal acts under No. 11958) (hereinafter - Order 626).

      4. Examinations by nurses (hereinafter referred to as the Nurses), primary care physician, and a subject matter specialist are carried out in accordance with Order 281 and Order 626.

      5. Observation, including diagnostic tests, of patients with diseases not provided for in Order 281 and Order 626, is carried out in accordance with the list of guaranteed volume of free medical care, approved by the resolution of the Government of the Republic of Kazakhstan dated December 15, 2009 No. 2136 and clinical protocols.

      6. Drug provision for patients with chronic diseases is carried out in accordance with subparagraph 2) of paragraph 1 of Article 88 of the Code.

      7. Dynamic observation of patients with chronic diseases is carried out by specialists of primary health care organizations: primary care physicians (district physicians and pediatricians, general practitioners), nurses (district nurse of a medical clinic and (or) clinic, nurse of a medical center, (or) paramedic of a medical and obstetrical station).

      If necessary, social workers, psychologists and specialists of the healthy lifestyle cabinet (hereinafter referred to as the HLS specialist) are involved.

      8. Dynamic observation of persons with chronic diseases is carried out in order to timely detect, prevent complications, exacerbations of diseases, their prevention and medical rehabilitation of these persons.

      9. Dynamic observation is carried out in the conditions of a medical center, a medical and obstetrical station, medical dispensary, primary care center, clinic (district, city) and other organizations providing primary care, depending on the place of attachment of the patient.

Chapter 2. Procedure for dynamic observation of patients with chronic diseases

      10. A patient is registered for dynamic observation in the PHC organization at the place of attachment on the basis of one of three documents:

      1) the conclusions of the PHC physician;

      2) the advisory opinion of a subject matter specialist;

      3) extracts from the medical record of the inpatient.

      11. Registration of a patient with a chronic disease is carried out by a nurse by filling out a clinical record checklist in the form No. 030 / у (hereinafter - form 030 / у), approved by the order of the Minister of Health of the Republic of Kazakhstan dated November 23, 2010 No. 907 “On approval of forms of primary medical documentation of healthcare organizations” (registered in the Register of state registration of regulatory legal acts under No. 6697) (hereinafter - Order No. 907).

      12. When registering, a nurse conducts an initial examination of the patient, informs him about the list, volumes, frequency of the medical examination by a nurse, a primary care physician, a subject matter specialist, laboratory and instrumental studies, observation periods, gives recommendations for a healthy lifestyle, reports the date of the next appearance indicating the date in the form 030 / y.

      13. When registering patients with chronic diseases according to the list of diseases according to Order 281, the primary care physician conducts an initial examination of the patient and draws up an individual treatment plan, fills out the form 030 / y, which is stored electronically in the primary health care organization.

      14. A nurse monitors the implementation of the treatment.

      15. When registering patients with chronic diseases according to the list of diseases according to Order 626, the primary care physician conducts an initial examination of the patient and prescribes treatment in accordance with the recommendations of the relevant subject matter specialist who provided the CDA.

      16. The list, volumes, frequency of medical examinations by nurses, PHC physicians, subject matter specialists, laboratory and instrumental examinations, observation periods, and deregistration criteria are determined by Order 281 and Order 626.

      17. At the repeated appearances, the nurse interrogates the patient, conducts a physical examination, and sends him to laboratory and instrumental studies in accordance with Order 281 and Order 626.

      18. In the absence of complaints, signs of exacerbation and progression of the disease during physical examination, deviations of the results of laboratory and instrumental studies from the norms, the nurse:

      talks and gives recommendations on a healthy lifestyle, if necessary, sends to HLS specialists,

      explains to the patient with a high risk of developing complications or a life-threatening condition the rules of action in case of their development and the need for timely emergency call.

      writes out recipes;

      appoints the date of the next appearance indicating the date in the form 030 / y.

      If there are complaints, signs of exacerbation, complication and progression of the disease according to the results of the examination, deviations of the results of laboratory and instrumental studies from the norms, the nurse sends the patient to the primary care physician for an unscheduled examination.

      19. A primary care physician examines a patient with a chronic disease under the referral from a nurse, as well as in a planned manner at intervals in accordance with Order 281 and Order 626.

      20. During dynamic observation of a patient with a chronic disease, a primary care physician performs:

      1) an initial examination, collection, recording of complaints and medical history;

      2) physical examination of the patient;

      3) monitoring of the implementation of the individual treatment plan developed jointly with the patient in accordance with Order 281;

      4) assessment of the results of diagnostic studies;

      5) assessment of the results of the training for self-assistance of a patient, depending on the disease;

      6) adjustment of an individual plan for non-drug and drug treatment, a diary of patient self-monitoring, taking into account the results of the examination, examination data, recommendations of subject matter specialists, healthy lifestyle specialists;

      7) issuance of recommendations for preparation of documents for sending to medical and social examination (hereinafter referred to as MSE), in accordance with the Rules for medical and social examination approved by the order of the Minister of Health and Social Development of the Republic of Kazakhstan dated January 30, 2015 No. 44 (registered in the Register of state registration of regulatory legal acts under No. 10589), in the presence of a medical information system in electronic format;

      8) referral for medical rehabilitation in accordance with the standard of the organization of medical rehabilitation for the population of the Republic of Kazakhstan, approved by the order of the Minister of Health of the Republic of Kazakhstan dated December 27, 2013 No. 759 (registered in the Register of state registration of regulatory legal acts under No. 9108) (hereinafter - Order No. 759), in the presence of a medical information system in electronic format;

      9) referral to a hospital-replacing and (or) inpatient treatment upon detection of signs of exacerbation and progression of the disease, the availability of indications for medical observation in stationary conditions.

      21. In the absence of complaints, signs of complication and progression of the disease according to the results of the examination, deviations of laboratory and instrumental studies from the norms in patients with chronic diseases according to Order 281, the primary care physician conducts treatment corrections and gives recommendations for a healthy lifestyle.

      22. Within the time limit according to Order 281 and Order 626, a patient with a chronic disease is subject to examination by a subject matter specialist.

      23. A subject matter specialist submits to the primary care physician a medical report in the form No. 071 / у, approved by the order No. 907 (hereinafter referred to as the consultative and diagnostic report), which indicates the results of the examination and recommendations for further treatment of the patient, in the presence of a medical information system in electronic format.

      24. The primary care physician, after receiving the consultative and diagnostic report, carries out further monitoring of the patient in accordance with the recommendations of the relevant subject matter specialist.

      25. In the presence of indications, a patient is sent for hospitalization in a round-the-clock or day hospital in accordance with the profile of the disease.

      Inpatient care for people with chronic diseases is provided in accordance with the Rules for provision of inpatient care, approved by the order of the Minister of Health and Social Development of the Republic of Kazakhstan dated September 29, 2015 No. 761 (registered in the Register of state registration of regulatory legal acts under No. 12204).

      Hospital-replacing care is provided in accordance with the Rules for provision of hospital-replacing care approved by the order of the Minister of Health and Social Development of the Republic of Kazakhstan dated August 17, 2015 No. 669 (registered in the Register of state registration of regulatory legal acts under No. 12106).

      26. A physician at the day or round-the-clock hospital, upon discharge, draws up an extract from the medical record of the inpatient in the form 027 / y, approved by the order No. 907, indicating the amount of diagnostic tests, medical measures and recommendations for further observation and treatment. An electronic version of the extract is sent to the PHC organization at the place of attachment.

      27. A primary care physician after receiving an extract from a medical record of the inpatient, including in e-health systems, carries out further observation of the patient, taking into account the recommendations of the physician of a day or round-the-clock hospital.

      28. Control over the organization of work of nurses on the issues of dynamic observation, including record keeping and the information system, is carried out by a primary care physician and the head of a medical organization.

      29. When sending a patient with a chronic disease to the responsible PHC nurses for dynamic observation, a social worker:

      1) provides assistance to patients with a chronic disease and their close relatives in determining their own needs for social assistance, protection and services in accordance with the approved standards for provision of social assistance;

      2) when sending to the responsible PHC nurses, visits a patient with a chronic disease at home who cannot cope with keeping a diary, does not reach the target indicators of the patient’s individual plan of self-control (for example, target numbers of blood pressure, blood sugar, lipids, weight loss, calls for an ambulance, goes to the hospital etc.) to identify obstacles and provide all possible assistance for self-assistance.

      30. When sending a patient with a chronic disease for dynamic observation to the responsible PHC nurses, a psychologist:

      1) conducts psychological counseling of patients, as well as work on psycho-correction;

      2) provides assistance to patients and their relatives in solving personal, professional and everyday psychological problems.

      31. When sending a patient with a chronic disease to the responsible PHC nurses for dynamic observation, a healthy lifestyle specialist:

      1) conducts training in practical skills in non-drug treatment prescribed by a primary care physician;

      2) conducts group and individual work on hygienic education among people with chronic forms of diseases and people with an increased risk of disease;

      3) participates in the organization of work of specialized health schools.

Chapter 3. Dynamic observation of patients with chronic diseases in the framework
of the Disease Management Program

      32. During a dynamic observation, specialists select patients for participation in the disease management program (hereinafter referred to as DMP) for three ICD diseases: arterial hypertension, type 2 diabetes mellitus, and chronic heart failure.

      33. The criteria for the selection of patients participating in the DMP are:

      patients with primary arterial hypertension (uncomplicated);

      patients with type 2 diabetes mellitus (compensated and sub-compensated);

      NYHA grade II-IV chronic heart failure patients with an ejection fraction of less than 40% or an ejection fraction of more than 40% and diastolic dysfunction of the left ventricle according to echocardiography.

      34. Patients with multiple diseases that meet the selection criteria set out in paragraph 33 may participate in the DMP.

      35. With the consent of the patient for participation in the DMP, the nurses conclude a contract in accordance with the Civil Code of the Republic of Kazakhstan. The nurses enter the electronic form of the contract on participation in DMP in the information system “Unified Payment System” or in the medical information system.

      36. Observation of a patient under the DMP is carried out by specialists of the PHC site, who have relevant certificates of professional development. The coordinator of the DMP within the PHC site is the district physician (general practitioner, district physician (pediatrician)).

      37. For the effective introduction of the DMP in PHC organizations, it is recommended to create a multidisciplinary group (hereinafter - MDG), consisting of PHC specialists, an engaged psychologist, a healthy lifestyle specialist, a subject matter specialist and other interested specialists.

      38. During the dynamic observation of patients under the DMP, the primary care physician and the nurses, by competency, fills in the observation card for the patient participating in the DMP. Information about the patient, objective examination data, results of laboratory and instrumental research methods are entered into the observation card.

      39. The observation card is filled in at each patient visit to the primary health care organization, followed by the entry of the updated medical data by the nurses into the patient registry of the DMP patients.

      40. Based on the data of the register of DMP patients, the primary care physician regularly performs segmentation of patients. As a result of segmentation of patients, the multiplicity of dynamic observation (examination by nurses and primary care physician), laboratory and instrumental studies, and examinations of subject matter specialists are determined.

      41. The organization of the planned admission of patients is carried out by the nurses. Notification of patients participating in the DMP is carried out in accordance with the list formed in the registry of DMP patients by telephone, SMS, social networks, mobile applications.

      42. Notification (calls to) of patients is also carried out to invite to laboratory and instrumental studies to ensure subsequent observation of the patient.

      43. Primary care specialists teach the patient the self-assistance elements, taking into account the level of individual characteristics of the patient.

      44. Within the DMP framework, the patient draws up an individual action plan for a short period (no more than 2 weeks), including the amount of physical activity, diet, lifestyle, elimination of bad habits.

      45. Monitoring of the program efficiency is assessed based on the achievement of target indicators.

Chapter 4. Final provisions

      46. Deregistration of persons with chronic diseases is carried out according to the criteria and time limits in accordance with Order 281 and Order 626.

      47. The reasons for termination of dynamic observation of patients with chronic diseases in the PHC organization are:

      1) change of place of attachment (ensuring the transfer of the asset to the PHC organization at the place of attachment of the patient);

      2) a written refusal of the patient;

      3) the death of the patient.

Назад к документу

On approval of the Rules for dynamic observation of patients with chronic diseases (changes for 30 марта 2019) V1900018474

Order of the Minister of Health of the Republic of Kazakhstan dated March 30, 2019 No. ҚР ДСМ-16. Registered in the Ministry of Justice of the Republic of Kazakhstan on April 8, 2019 No. 18474

      Order of the Minister of Health of the Republic of Kazakhstan dated March 30, 2019 No. ҚР ДСМ-16. Registered in the Ministry of Justice of the Republic of Kazakhstan on April 8, 2019 No. 18474

      Unofficial translation

      In accordance with subparagraph 127) of paragraph 1 of Article 7 of the Code of the Republic of Kazakhstan dated September 18, 2009 "On people’s health and healthcare system", I HEREBY ORDER:

      1. To approve the attached Rules for dynamic observation of patients with chronic diseases.

      2. The Department of organization of medical care of the Ministry of Health of the Republic of Kazakhstan, in the manner prescribed by law, to ensure:

      1) state registration of this order in the Ministry of Justice of the Republic of Kazakhstan;

      2) within ten calendar days from the date of the state registration of this order, sending of its copy in electronic form in the Kazakh and Russian languages to the Republican state enterprise on the basis of the right of economic management “Republican Legal Information Center” for official publication and inclusion in the Reference Control Bank of regulatory legal acts of the Republic of Kazakhstan;

      3) placement of this order on the Internet resource of the Ministry of Health of the Republic of Kazakhstan;

      4) within ten working days after the state registration of this order in the Ministry of Justice of the Republic of Kazakhstan, submission of information to the Department of Legal Services of the Ministry of Health of the Republic of Kazakhstan on implementation of measures provided for in subparagraphs 1), 2) and 3) of this paragraph.

      3. Vice Minister of Health of the Republic of Kazakhstan L.M. Aktayeva shall be authorized to oversee the execution of this order.

      4. This order shall come into force ten calendar days after the day of its first official publication.

      Minister of Health of the
      Republic of Kazakhstan Ye. Birtanov

  Approved
by the order of the Minister of Health of the Republic of Kazakhstan dated March 30, 2019 № ҚР ДСМ-16

Rules for dynamic observation of patients with chronic diseases

Chapter 1. General provisions

      1. These Rules for dynamic observation of patients with chronic diseases (hereinafter referred to as the Rules) are developed in accordance with subparagraph 127) of paragraph 1 of Article 7 of the Code of the Republic of Kazakhstan dated September 18, 2009 “On people’s health and healthcare system” (hereinafter - the Code) and determine the procedure for dynamic observation of patients with chronic diseases.

      2. The basic concepts used in these Rules are:

      1) primary health care (hereinafter referred to as PHC) - pre-medical or qualified medical care without round-the-clock medical supervision, including a range of available medical services provided at the level of a person, family and society;

      2) a subject matter specialist - a medical specialist with a higher medical education who has a certificate in a particular specialty;

      3) dynamic observation - systematic monitoring of the state of people’s health, as well as the provision of necessary medical care based on the results of this observation;

      4) clinical protocol - a document establishing the general requirements for provision of medical care to a patient in a particular disease or clinical situation;

      5) consultative and diagnostic assistance (hereinafter - CDA) – a specialized medical care, including with the use of high-tech medical services without round-the-clock medical supervision.

      3. Dynamic observation of patients with chronic diseases is carried out:

      according to the list of diseases subject to dynamic observation in primary health care organizations and within the framework of the disease management program, in accordance with the PHC Rules approved by the order of the Minister of Health and Social Development of the Republic of Kazakhstan dated April 28, 2015 No. 281 (registered in the Register of state registration of regulatory legal acts under No. 11268) (hereinafter referred to as Order 281);

      according to the list of diseases subject to dynamic observation within the framework of consultative and diagnostic assistance, in accordance with the CDA Rules, approved by the order of the Minister of Health and Social Development of the Republic of Kazakhstan dated July 28, 2015 No. 626 (registered in the Register of state registration of regulatory legal acts under No. 11958) (hereinafter - Order 626).

      4. Examinations by nurses (hereinafter referred to as the Nurses), primary care physician, and a subject matter specialist are carried out in accordance with Order 281 and Order 626.

      5. Observation, including diagnostic tests, of patients with diseases not provided for in Order 281 and Order 626, is carried out in accordance with the list of guaranteed volume of free medical care, approved by the resolution of the Government of the Republic of Kazakhstan dated December 15, 2009 No. 2136 and clinical protocols.

      6. Drug provision for patients with chronic diseases is carried out in accordance with subparagraph 2) of paragraph 1 of Article 88 of the Code.

      7. Dynamic observation of patients with chronic diseases is carried out by specialists of primary health care organizations: primary care physicians (district physicians and pediatricians, general practitioners), nurses (district nurse of a medical clinic and (or) clinic, nurse of a medical center, (or) paramedic of a medical and obstetrical station).

      If necessary, social workers, psychologists and specialists of the healthy lifestyle cabinet (hereinafter referred to as the HLS specialist) are involved.

      8. Dynamic observation of persons with chronic diseases is carried out in order to timely detect, prevent complications, exacerbations of diseases, their prevention and medical rehabilitation of these persons.

      9. Dynamic observation is carried out in the conditions of a medical center, a medical and obstetrical station, medical dispensary, primary care center, clinic (district, city) and other organizations providing primary care, depending on the place of attachment of the patient.

Chapter 2. Procedure for dynamic observation of patients with chronic diseases

      10. A patient is registered for dynamic observation in the PHC organization at the place of attachment on the basis of one of three documents:

      1) the conclusions of the PHC physician;

      2) the advisory opinion of a subject matter specialist;

      3) extracts from the medical record of the inpatient.

      11. Registration of a patient with a chronic disease is carried out by a nurse by filling out a clinical record checklist in the form No. 030 / у (hereinafter - form 030 / у), approved by the order of the Minister of Health of the Republic of Kazakhstan dated November 23, 2010 No. 907 “On approval of forms of primary medical documentation of healthcare organizations” (registered in the Register of state registration of regulatory legal acts under No. 6697) (hereinafter - Order No. 907).

      12. When registering, a nurse conducts an initial examination of the patient, informs him about the list, volumes, frequency of the medical examination by a nurse, a primary care physician, a subject matter specialist, laboratory and instrumental studies, observation periods, gives recommendations for a healthy lifestyle, reports the date of the next appearance indicating the date in the form 030 / y.

      13. When registering patients with chronic diseases according to the list of diseases according to Order 281, the primary care physician conducts an initial examination of the patient and draws up an individual treatment plan, fills out the form 030 / y, which is stored electronically in the primary health care organization.

      14. A nurse monitors the implementation of the treatment.

      15. When registering patients with chronic diseases according to the list of diseases according to Order 626, the primary care physician conducts an initial examination of the patient and prescribes treatment in accordance with the recommendations of the relevant subject matter specialist who provided the CDA.

      16. The list, volumes, frequency of medical examinations by nurses, PHC physicians, subject matter specialists, laboratory and instrumental examinations, observation periods, and deregistration criteria are determined by Order 281 and Order 626.

      17. At the repeated appearances, the nurse interrogates the patient, conducts a physical examination, and sends him to laboratory and instrumental studies in accordance with Order 281 and Order 626.

      18. In the absence of complaints, signs of exacerbation and progression of the disease during physical examination, deviations of the results of laboratory and instrumental studies from the norms, the nurse:

      talks and gives recommendations on a healthy lifestyle, if necessary, sends to HLS specialists,

      explains to the patient with a high risk of developing complications or a life-threatening condition the rules of action in case of their development and the need for timely emergency call.

      writes out recipes;

      appoints the date of the next appearance indicating the date in the form 030 / y.

      If there are complaints, signs of exacerbation, complication and progression of the disease according to the results of the examination, deviations of the results of laboratory and instrumental studies from the norms, the nurse sends the patient to the primary care physician for an unscheduled examination.

      19. A primary care physician examines a patient with a chronic disease under the referral from a nurse, as well as in a planned manner at intervals in accordance with Order 281 and Order 626.

      20. During dynamic observation of a patient with a chronic disease, a primary care physician performs:

      1) an initial examination, collection, recording of complaints and medical history;

      2) physical examination of the patient;

      3) monitoring of the implementation of the individual treatment plan developed jointly with the patient in accordance with Order 281;

      4) assessment of the results of diagnostic studies;

      5) assessment of the results of the training for self-assistance of a patient, depending on the disease;

      6) adjustment of an individual plan for non-drug and drug treatment, a diary of patient self-monitoring, taking into account the results of the examination, examination data, recommendations of subject matter specialists, healthy lifestyle specialists;

      7) issuance of recommendations for preparation of documents for sending to medical and social examination (hereinafter referred to as MSE), in accordance with the Rules for medical and social examination approved by the order of the Minister of Health and Social Development of the Republic of Kazakhstan dated January 30, 2015 No. 44 (registered in the Register of state registration of regulatory legal acts under No. 10589), in the presence of a medical information system in electronic format;

      8) referral for medical rehabilitation in accordance with the standard of the organization of medical rehabilitation for the population of the Republic of Kazakhstan, approved by the order of the Minister of Health of the Republic of Kazakhstan dated December 27, 2013 No. 759 (registered in the Register of state registration of regulatory legal acts under No. 9108) (hereinafter - Order No. 759), in the presence of a medical information system in electronic format;

      9) referral to a hospital-replacing and (or) inpatient treatment upon detection of signs of exacerbation and progression of the disease, the availability of indications for medical observation in stationary conditions.

      21. In the absence of complaints, signs of complication and progression of the disease according to the results of the examination, deviations of laboratory and instrumental studies from the norms in patients with chronic diseases according to Order 281, the primary care physician conducts treatment corrections and gives recommendations for a healthy lifestyle.

      22. Within the time limit according to Order 281 and Order 626, a patient with a chronic disease is subject to examination by a subject matter specialist.

      23. A subject matter specialist submits to the primary care physician a medical report in the form No. 071 / у, approved by the order No. 907 (hereinafter referred to as the consultative and diagnostic report), which indicates the results of the examination and recommendations for further treatment of the patient, in the presence of a medical information system in electronic format.

      24. The primary care physician, after receiving the consultative and diagnostic report, carries out further monitoring of the patient in accordance with the recommendations of the relevant subject matter specialist.

      25. In the presence of indications, a patient is sent for hospitalization in a round-the-clock or day hospital in accordance with the profile of the disease.

      Inpatient care for people with chronic diseases is provided in accordance with the Rules for provision of inpatient care, approved by the order of the Minister of Health and Social Development of the Republic of Kazakhstan dated September 29, 2015 No. 761 (registered in the Register of state registration of regulatory legal acts under No. 12204).

      Hospital-replacing care is provided in accordance with the Rules for provision of hospital-replacing care approved by the order of the Minister of Health and Social Development of the Republic of Kazakhstan dated August 17, 2015 No. 669 (registered in the Register of state registration of regulatory legal acts under No. 12106).

      26. A physician at the day or round-the-clock hospital, upon discharge, draws up an extract from the medical record of the inpatient in the form 027 / y, approved by the order No. 907, indicating the amount of diagnostic tests, medical measures and recommendations for further observation and treatment. An electronic version of the extract is sent to the PHC organization at the place of attachment.

      27. A primary care physician after receiving an extract from a medical record of the inpatient, including in e-health systems, carries out further observation of the patient, taking into account the recommendations of the physician of a day or round-the-clock hospital.

      28. Control over the organization of work of nurses on the issues of dynamic observation, including record keeping and the information system, is carried out by a primary care physician and the head of a medical organization.

      29. When sending a patient with a chronic disease to the responsible PHC nurses for dynamic observation, a social worker:

      1) provides assistance to patients with a chronic disease and their close relatives in determining their own needs for social assistance, protection and services in accordance with the approved standards for provision of social assistance;

      2) when sending to the responsible PHC nurses, visits a patient with a chronic disease at home who cannot cope with keeping a diary, does not reach the target indicators of the patient’s individual plan of self-control (for example, target numbers of blood pressure, blood sugar, lipids, weight loss, calls for an ambulance, goes to the hospital etc.) to identify obstacles and provide all possible assistance for self-assistance.

      30. When sending a patient with a chronic disease for dynamic observation to the responsible PHC nurses, a psychologist:

      1) conducts psychological counseling of patients, as well as work on psycho-correction;

      2) provides assistance to patients and their relatives in solving personal, professional and everyday psychological problems.

      31. When sending a patient with a chronic disease to the responsible PHC nurses for dynamic observation, a healthy lifestyle specialist:

      1) conducts training in practical skills in non-drug treatment prescribed by a primary care physician;

      2) conducts group and individual work on hygienic education among people with chronic forms of diseases and people with an increased risk of disease;

      3) participates in the organization of work of specialized health schools.

Chapter 3. Dynamic observation of patients with chronic diseases in the framework
of the Disease Management Program

      32. During a dynamic observation, specialists select patients for participation in the disease management program (hereinafter referred to as DMP) for three ICD diseases: arterial hypertension, type 2 diabetes mellitus, and chronic heart failure.

      33. The criteria for the selection of patients participating in the DMP are:

      patients with primary arterial hypertension (uncomplicated);

      patients with type 2 diabetes mellitus (compensated and sub-compensated);

      NYHA grade II-IV chronic heart failure patients with an ejection fraction of less than 40% or an ejection fraction of more than 40% and diastolic dysfunction of the left ventricle according to echocardiography.

      34. Patients with multiple diseases that meet the selection criteria set out in paragraph 33 may participate in the DMP.

      35. With the consent of the patient for participation in the DMP, the nurses conclude a contract in accordance with the Civil Code of the Republic of Kazakhstan. The nurses enter the electronic form of the contract on participation in DMP in the information system “Unified Payment System” or in the medical information system.

      36. Observation of a patient under the DMP is carried out by specialists of the PHC site, who have relevant certificates of professional development. The coordinator of the DMP within the PHC site is the district physician (general practitioner, district physician (pediatrician)).

      37. For the effective introduction of the DMP in PHC organizations, it is recommended to create a multidisciplinary group (hereinafter - MDG), consisting of PHC specialists, an engaged psychologist, a healthy lifestyle specialist, a subject matter specialist and other interested specialists.

      38. During the dynamic observation of patients under the DMP, the primary care physician and the nurses, by competency, fills in the observation card for the patient participating in the DMP. Information about the patient, objective examination data, results of laboratory and instrumental research methods are entered into the observation card.

      39. The observation card is filled in at each patient visit to the primary health care organization, followed by the entry of the updated medical data by the nurses into the patient registry of the DMP patients.

      40. Based on the data of the register of DMP patients, the primary care physician regularly performs segmentation of patients. As a result of segmentation of patients, the multiplicity of dynamic observation (examination by nurses and primary care physician), laboratory and instrumental studies, and examinations of subject matter specialists are determined.

      41. The organization of the planned admission of patients is carried out by the nurses. Notification of patients participating in the DMP is carried out in accordance with the list formed in the registry of DMP patients by telephone, SMS, social networks, mobile applications.

      42. Notification (calls to) of patients is also carried out to invite to laboratory and instrumental studies to ensure subsequent observation of the patient.

      43. Primary care specialists teach the patient the self-assistance elements, taking into account the level of individual characteristics of the patient.

      44. Within the DMP framework, the patient draws up an individual action plan for a short period (no more than 2 weeks), including the amount of physical activity, diet, lifestyle, elimination of bad habits.

      45. Monitoring of the program efficiency is assessed based on the achievement of target indicators.

Chapter 4. Final provisions

      46. Deregistration of persons with chronic diseases is carried out according to the criteria and time limits in accordance with Order 281 and Order 626.

      47. The reasons for termination of dynamic observation of patients with chronic diseases in the PHC organization are:

      1) change of place of attachment (ensuring the transfer of the asset to the PHC organization at the place of attachment of the patient);

      2) a written refusal of the patient;

      3) the death of the patient.

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